Engaging Employers to Develop Healthy Workplaces: The WorkWell Initiative of Steps to a Healthier Washington in Thurston County

Background The WorkWell initiative of Thurston County, Washington, established by Steps to a Healthier Washington in Thurston County (Thurston County Steps), focuses on recognizing and supporting local employers who make a commitment to address workforce health issues by implementing programs within their organizations to help adults reach Healthy People 2010 objectives. This article reports on the WorkWell initiative and resulting WorkWell program. Context The WorkWell initiative was developed to address the needs of private and public employers in Thurston County, Washington, to reduce the prevalence of chronic diseases through policy, practice, and environmental changes. Methods Thurston County Steps recruited local employers to participate in advisory work groups to identify healthy workplace interventions that would be feasible for the employers and initiate a shift in organizational culture. The WorkWell initiative developed 2 distinct approaches — 1 for private sector (designation program) and another for public sector (action planning). Consequences Twenty-six employers with approximately 4,700 employees were recognized with WorkWell Healthy Workplace designations for implementing changes that included encouraging stairwell use, providing low- or no-cost healthy meals for employees, and providing healthy foods at meetings. Four public agencies with approximately 4,400 employees have participated in an assessment and action planning process to help government employers focus their efforts and resources to support workforce health promotion. Interpretation Unique partnerships between Thurston County Steps and other employers, private and public, demonstrate the important role employers can play in reducing chronic disease to improve a community's overall health.


Background
In the United States, chronic disease accounts for 7 of the 10 leading causes of death (1) and affects the quality of life of 90 million Americans. Identifying effective and sustainable strategies to influence behavior at the local level is critical when addressing disability, health care costs, and the increasing prevalence of chronic diseases (2). Because most adults spend half of their waking hours at work, employers have a unique opportunity to create a The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
work culture that improves the health of their workforce. Employees in optimal health are more likely to be on the job and performing well. They are also more likely to seek out jobs in these organizations and remain with an employ er that values their health (3). Organizational support of health programs reduces employee turnover and has both fiscal and human resource benefits for employers (4,5).
In 2003, Washington State Department of Health (DOH) was 1 of 4 state health departments to be funded through a cooperative agreement from the Centers for Disease Control and Prevention (CDC). CDC's Steps Program pro vided federal funding for states, cities, and tribal entities to implement chronic disease prevention efforts to reduce the prevalence of obesity, diabetes, and asthma. Steps to a Healthier Washington in Thurston County (Thurston County Steps) was 1 of the 4 communities selected to work on this program in Washington State. The program focused on 3 related risk factors -physical inactiv ity, poor nutrition, and tobacco use -in Washington's health care industries, worksites, and schools. The Steps to a Healthier Washington program has used these fed eral funds in Washington's communities and across the domains to address asthma, nutrition, diabetes, tobacco use, and physical activity. The socioecologic model (6) provides a foundation for this multisector approach and addresses many behavioral determinants of health and many levels at which intervention can occur.
Thurston County Public Health, the Thurston County Chamber of Commerce, and various private and public employers used a model that empowers local communities to make sustainable changes through policy, collaborative leadership, and community mobilization, to develop the WorkWell initiative. The initiative encourages employers to adopt organizational policy, practice, and environmen tal change as a core strategy for workforce health promo tion. Many employers, regardless of size or industry type, have found that addressing workforce health is not only desirable but also attainable. Organizational policies, a supportive social and built environment, and systemwide workplace practices help foster an organizational culture that facilitates healthy behaviors. Organizational poli cies, the formal rules that guide organizations, can exist in more forms than public policy or changes in law. They can change the way systems and institutions do business and can be voluntarily adopted by workplaces, schools, and other communitybased organizations. Workplace practices are informal, unwritten expectations about the "way we do business." These kinds of practices reflect priorities and values of an employer, which then influence and shape workplace culture. A workplace culture that supports healthy lifestyles, where healthier choices have been made more accessible, can help change a person's overall health. Changes such as these typically have greater effect and sustainability (7,8).

Context
Thurston County is in western Washington State and is the center for state government as well as a regional hub for medical services. The county has a population of 245,300, the seventh largest in the state. It is both urban and rural, with cities ranging from 660 to 44,800 residents (9). The county is a regional center for employment with approximately 129,200 jobs. Nearly 37,200 of these full or parttime jobs are in federal, state, or local government (10). Thurston County Steps, led by the Thurston County Public Health and Social Services Department, aims to affect the county's total population with emphasis on spe cific subpopulations by 1) implementing chronic disease prevention intervention programs and 2) working collab oratively with people who are influential in key aspects of the community (eg, neighborhood associations for built environment changes, health care providers for diabetes management, school districts for access to healthy food options). Thurston County Steps identified a need to develop a worksite health initiative to address public and private employers of all sizes and implement organiza tional policy, practice, and environmental changes that reduce the prevalence of chronic disease. The initiative attempted to reach small businesses like a graphic design firm and an office supply store (<50 employees), midsized commercial banks and local governments like the port and regional library district (up to 250 employees), and larger private businesses such as hospitals and state government agencies (>250 employees up to the largest at approxi mately 2,250).

Methods
In 2004, Thurston County Steps recruited local employ ers from public and private organizations to identify work place interventions that would be feasible for the employer and to improve employee health through workplace policy, practice, and environment changes. Employerbased advi The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
sory work groups were formed in 2005 to identify ways to raise awareness of health promotion strategies that could be used to improve employee health, decrease absentee ism, and reduce health care costs. The Thurston County Steps work groups' efforts led to the WorkWell initiative. Two different approaches were created to account for the differences in organizational culture, workforce composi tion, and resources among private and public employers. These approaches include specific evidencebased changes to the culture and environment of the workplace.

Private sector WorkWell: Healthy Workplace Designation Program
With the help of a local private business owner, the Thurston County Steps program approached the Thurston County Chamber of Commerce about developing a joint venture aimed at private employers. The WorkWell Healthy Workplace Designation Program was developed during the first 6 months of 2006 to recognize the com mitment and changes that employers made to support healthy eating and physical activity during work hours. The goal of the approach is to emphasize the many ways to bring about meaningful change within the workplace. Employers are invited to apply for recognition through the WorkWell Healthy Workplace Designation Program by documenting environmental and policy changes along with organizational commitment to health in the work place from the previous year (8). Employers are recruited by direct marketing in email, advertisement, and public ity on the Web sites of the chamber and the Thurston County Public Health and Social Services Department, in the chamber's monthly magazine, and through distribut ing program materials at chamber events.
The WorkWell program features 3 designation levels -bronze, silver, and gold. The bronze recognition is awarded to employers who demonstrate organizational support for changes to the work environment or cul ture that can affect healthy eating or physical activity. Examples of organizational support that qualify include expanding the organization's vision or strategic plan to incorporate employee health and fitness or starting a com mittee focusing on workforce health that allows employees in different job classes to assist in the design and imple mentation of plans for change. The silver recognition is awarded to employers who meet the criteria for bronze and have supported specific changes to the work environ ment that either 1) made healthier food choices available or more accessible to employees or 2) made engaging in physical activity during work hours an option or an easier choice for employees (11). The gold recognition is awarded to employers who have met the criteria for bronze and have supported changes that address both the healthy eating and physical activity criteria for silver. Types of qualifying efforts in the healthy eating category include creating a healthy food guideline for use when planning employersponsored events, having healthy food choices available in onsite vending or snack bars, and providing a refrigerator, microwave, and sink at no cost to employees. Examples of physical activity interventions include offer ing flexible break times and lunches on a rotating basis so employees can take advantage of physical activities, creating walking maps for destinations within 1 mile of the workplace, providing umbrellas for walking in rainy weather, and developing a policy that rewards employees who use a physically active way to travel to work. A review committee composed of local employers and Thurston chamber staff helped evaluate the applicants.
Recognized employers are given WorkWell decals that they can display on their entrance doors. The Thurston County Chamber of Commerce hosts a forum focused on awarding the designations, which in 2008 was attended by approximately 170 local employers. Employers are also honored in ways that communicate their unique approach to employee health and evidencebased strategies to their peers. Employers who receive the designation award are featured in an online video series promoted by the busi ness community newspaper, a monthly magazine, and on the Thurston County Chamber of Commerce Web site.

Public sector WorkWell: Action Planning for a Healthy Workforce
The WorkWell approach for public employers involves a guided selfassessment and action planning process called Action Planning for a Healthy Workforce. This process was designed to support employers who are ready to take a closer look at key organizational issues that affect employ ee health and fitness. Thurston County Steps developed the selfassessment tool and related promotional materials with an advisory committee consisting of managers and staff from local public sector (government) employers of varying sizes and workforce compositions.
The Action Planning for a Healthy Workforce process focuses on chronic disease areas that are consistent with The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
the Steps Program's target areas and were supported by the DOH evidencebased state plans (physical activity and nutrition [11], asthma [12] and tobacco use [13]). The self assessment tool highlights 3 key components of workforce health promotion: 1) expression of leadership support and commitment to employee health (1418), 2) expansion of written polices or formal practices in the organization (11,1719), and 3) environmental assets and supports throughout the workplace (11).
The assessment and action planning process assumes that meaningful, longterm change must focus on both individual behavior (ie, employees) and organizational level action (ie, worksites and employers). The belief that people shape, and are shaped by, their work environment is a key tenet of this model (Figure). Interested employ ers participate in a 2stage process that provides decision makers with information to plan changes that would most benefit their organizations and workforces. The process starts with the facilitated completion of a selfassessment tool that identifies organizational strengths in relation to current healthrelated policy and practices. Employers are then invited to participate in a facilitated action plan ning process that identifies workforce health strategies designed to fit the employer's needs. The Healthy Workforce assessment tool covers 4 main topics: 1) workforce health promotion, 2) physical activity at work, 3) healthy eating during work hours, and 4) air quality in the workplace. This assessment provides insight around characteristics of organizations that have been linked to successful changes in workforce health, includ ing leadership support for workforce health and capacity for promoting change; a work environment organized or designed to make healthy choices easier; and culture of the organization, as demonstrated through written policies, formal practices, and communication. The assessment tool was developed by Thurston County Steps staff with expertise in program development, strategic planning, and organizational assessment.
The assessment is designed to be carried out by an assessment team consisting of the workplace's employees, thus involving the population affected by the possible actions and assuring greater accuracy and reliability in the data collection. The workforce perspectives included on the assessment team are senior leadership or policy makers, middle management, employee benefits, bargain ing units, building maintenance or facilities management, internal wellness groups, and contract managers (eg, managing the services provided by food vendors, other worksite suppliers). Employers set their own timeline for the planning process; however, a 6 to 10week schedule is recommended. Only 2 meetings of the full assessment team are needed to complete the selfassessment: a first for orientation and a second for scoring after the assess ment data has been collected. A 2person team of out reach and assessment staff from Thurston County Steps facilitate both the assessment and action planning phases and prepare the assessment report for the organization. The process was piloted with the Thurston County Public Health and Social Services Department, then became available for use with publicsector employers throughout the county.
In 2007, DOH became the first partner with the Thurston County Steps program to implement the assessment and action planning process to identify pri ority areas in their own agency. DOH chose this process as a way to address environmental and policy issues in the agency's overall health and productivity work. The agency followed the process described above, and Thurston County Steps reported results of the assess ment back to DOH leadership. This report and the facilitation provided by Thurston County Steps helped DOH develop a baseline and prioritize work from its overall comprehensive plan. Thurston County Steps staff worked with DOH Health and Productivity Team members to develop an action plan based on identified agency priorities.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.

Private sector WorkWell: Healthy Workplace Designation Program
In the first 2 years of the initiative in the private sector, 26 employers representing small and large workforces totaling approximately 4,700 employees, were awarded WorkWell designations (Table). Awardees received recog nition for implementing changes that encouraged physi cal activity and healthy eating, such as making stairwells more appealing for physical activity, lowcost or nocost healthy meals for employees, and healthy foods for meet ings. Nineteen of the employers have been recognized with gold designation. From the first to the second year of the program, the number of employers who applied for recognition doubled (Table). Participating employers included banks, credit unions, social services agencies, a hospital, a casino, and several city and county govern ment agencies.
The Thurston County Chamber of Commerce broadened its vision to encompass workplace health and began to fea ture WorkWell as one of the main programs for its members and other employers. The chamber signed a memorandum of agreement with Thurston County Public Health and Social Services Department to continue the collaboration around workplace health promotion. The chamber's Web site now promotes WorkWell and provides employers with examples of organizational support and healthy eating and physical activity options that they can implement to reach different designation levels. The WorkWell Healthy Workplace Designation Program was designed so that the Thurston County Chamber of Commerce became the lead entity for its implementation, further sustaining this valuable employer resource. The partnership will be sus tained through funding provided by the US Department of Health and Human Services, Office on Women's Health Advancing System Improvements to Support Targets for Healthy People 2010 (ASIST2010) program.

Public sector WorkWell: Action Planning for a Healthy Workforce
Through September 2008, in addition to Washington State Department of Health and the Thurston County Public Health and Social Services Department, another state agency, a regional education service district, and a local government employer -together employing approxi mately 4,400 people -have completed the assessment, which demonstrates the versatility of this approach and its applicability to diverse public employers (Table). Three current employer partners are considering 18 workplace environment and policy changes.
Thurston County Steps has developed a sustainability plan for the public sector element of the WorkWell initia tive. This plan includes exploring the interest among other public employers, particularly state agencies, in providing funding for the staff support provided by the Thurston County Public Health and Social Services Department. Thurston County Steps is also examining ways so that others can carry out the assessment and action planning process or repeat the process to reassess the workplace environment and policies as changes are being made. Thurston County Steps also revised the selfassessment tool based on comments and suggestions gathered during the first 2 years of its use.

Interpretation
Steps successes nationwide have been built in part on creating and strengthening publicprivate partnerships. Thurston County Steps' partnerships in the WorkWell ini tiative demonstrate that collaborative approaches can be used to address community priorities and implement pub lic health strategies that focus on the prevention and man agement of chronic disease. The benefits of partnerships are clear, but getting them established and operating in a sustainable manner that yields tangible results require careful consideration of diverse interests and needs of com munity partners. Unlike many federally funded commu nity programs, Steps has a broad mandate to deal with risk factors that cut across many diseases and is expected to reach across multiple domains to create communitybased solutions. This mandate has enabled Thurston County Steps to pull partners together to help create sustainable change. The initial leadership involvement from both pri vate and public sector employers led to 2 distinct programs that have responded to the needs of the diverse worksites of Thurston County communities. The unique partnerships between the Thurston County Chamber of Commerce, several public sector employers, and the Thurston County Public Health and Social Services Department demonstrate the important role business and governmental employ ers can play in reducing chronic disease and improving a community's overall health.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. MPA, RN, department director, and Linda C. Stewart, former Thurston County Steps program manager, all cur rently or formerly of the Thurston County Public Health and Social Services Department, for their leadership in creating a chronic disease prevention unit and collabora tive approach to community engagement; Thurston County WorkWell (Healthy Workforce) work group members and the Thurston County Chamber of Commerce, especially past board chair Mike Williams and President/CEO David Schaffert, who provided the support and committed their expertise and time to make the WorkWell initiative work to help Thurston County become a healthier community. We also thank the DOH for selecting Thurston County as a site in the Steps to a Healthier Washington program, and for its guidance as well as that of the DOH Health and Productivity Team, especially Robbi Kay Norman and Kari Ramirez for selecting the WorkWell initiative and for leading the Health and Productivity program in implementing and using the tool. We thank the US DHHS Office on Women's Health for providing ASIST2010 fund ing to sustain the WorkWell public health partnerships and systems change activities. We thank the Centers for Disease Control and Prevention for cooperative agreement no. 5 U58 DP02331705, which provided the funding to develop and implement the WorkWell healthy worksite interventions.